In an open letter, dozens of academics and health care providers voice their concerns about the regulation concerning euthanasia in the context of unbearable mental suffering (DM, 8/12). This concern is undoubtedly well intentioned but nonetheless misguided. The letter writers demand “objective” evidence of the irreversibility of psychological distress, such as an “organic injury or tissue damage.” They expect “factors that are independent of what is subjectively felt on the disease and is thought.” They wan to eliminate euthanasia based on “purely psychological suffering” from the current legislation. Particularly the word “merely” is very significant here.

We believe it is a misconception that only in cases of so-called physical suffering euthanasia is “responsible”. The demand to make suffering (and pain) “objectifiable” is a strange form of positivism and scientism. Do we have to ignore the repeated and clear testimony of people’s psychological suffering and not take it seriously as long as we cannot establish it scientifically? Do we address the ultimate request for help only when a brain scan demonstrates the suffering? The letter writers fail to appreciate not only the professional competence of doctors and therapists who establish the diagnosis, but they also want to turn the clock back by decades, by declaring patients incapable of expressing themselves about the nature and intensity of their suffering.

Hopeless suffering

Of course, suffering is subjective. How else could it be? If a person suffers, he or she is obviously the only one who can reasonably assess this experience. Suffering belongs to a subject. To ignore this subjective dimension showcases a lack of empathy. The letter writers’ comment that they are “alarmed by the increasing trivialisation of euthanasia on the grounds of psychological suffering” is therefore questionable.

In an interview with Bart Schols in The Appointment (8/12), Ariane Bazan, one of the initiators of the letter, refers to an article and the book by psychiatrist Lieve Thienpont, “Libera me: About euthanasia and psychological suffering.” The work of Lieve Thienpont apparently convinced her that euthanasia for psychological suffering must again be banned. That’s remarkable, since the book by Lieve Thienpont makes it precisely all too clear how hopeless the situation is of those who request euthanasia for reasons of psychological suffering. These are people who one often has tried to help for many years, with all the means that medicine and psychological support services have to offer. Some of these patients are so desperate that they commit suicide, with sometimes terrible and dehumanizing consequences.

Do the letter writers really think that the legislator, and the doctors who are willing to meet some (!) requests for help, tread so lightly with the request to bid farewell to life in a dignified manner? That they are not aware of the potential of various therapies and of the strict conditions for euthanasia in cases of psychological suffering? Precisely because psychological suffering is harder to measure, and a specific group of patients is not terminally ill, the legislator has added two additional criteria of good care for these patients to a euthanasia request: a second opinion by a psychiatrist and a minimum waiting period of one month.

The letter writers stick to a general discussion about the “feeling of hopelessness” that people experience when they are depressed, which for them is “in no way proportionate to the real hopelessness of a situation.” But obviously, not everyone with a depression qualifies for euthanasia without further therapeutic intervention. That is obvious. In practice, it concerns in our country about fifty people per year, a tiny fraction of the number of people going through a depression.

The letter writers’ dismissal of the hopeless suffering of this small group of people as “purely subjective”, a feeling that is an inherent part of depression, not only illustrates a lack of empathy; it also amounts to a paternalistic reflex: “You think you suffer hopelessly, but we know better. ” Incidentally, acute depression (eg. through a grieving process) usually interferes with the statutory requirement of voluntariness. In most cases of request for euthanasia, it involves other mental disorders, sometimes in combination with long-term chronic and treatment-resistant depression.

The false distinction between physical and psychological suffering

For the letter writers, the idea that the prospect of death can be part of good care amounts to “the radical failure of the mental health care sector”. This remarkable statement was a few decades ago still an often-heard objection in the euthanasia debate, also in the context of physical suffering, “Death is the enemy of medicine; when a physician reliefs someone from his misery, it means the failure of medical care.” Since then, we have come to know better. Unfortunately, the suffering of some patients is so unfathomably deep, that granting their request for an assisted medical and painless death remains the best thing the health sector has to offer. Ariane Bazan and her co-authors are apparently of the opinion that psychiatric patients’ treatments never end. That comes down to the idea that mental patients have no right to refuse treatment, which is completely contrary to the law on patients’ rights.

The euthanasia legislation is based on some fundamental philosophical principles related to a dignified end of life, in which empathy and self-determination are key. We see no good reason why patients who suffer unbearably psychologically, as unambiguously recognized by competent physicians and in line with the legislation, should be taken less seriously than those who are identified as suffering from a supposedly “objective physical” cause. By the way, people with an incurable physical illness also experience mental suffering. If we follow the logic of the letter writers, one can therefore contest the “unbearable” nature of each euthanasia request, which is a violation of the autonomy and therefore the dignity of any patient requesting euthanasia. The vast majority of caregivers today are not precipitating, nor was the legislator in 2002.